Study: PsA patients do better with aggressive treatment
Twice as many psoriatic arthritis patients saw a 70 percent improvement of their symptoms when doctors treated them more aggressively. The study, performed in the United Kingdom, compared patients on a standard treatment schedule with patients on a treatment schedule that more rapidly increased the dosing and introduced new drugs more quickly.
At the end of the 48-week trial, 38 percent of patients under the more aggressive treatment plan had experienced at least a 70 percent relief of symptoms. Only 17 percent experienced a similar amount of relief while undergoing a standard level of care. The findings were presented in October at the annual meeting of the American College of Rheumatology in San Diego by Dr. Laura Coates, a clinical lecturer at the Leeds Musculoskeletal Biomedical Research Unit of the National Institute for Health Research in the U.K.
All patients began treatment with methotrexate. Those under a "tight control" or "treat-to-target" drug regimen were assessed every four weeks according to objective criteria, which included how many of their joints were swollen. If no more than one of the patient's joints or tendons remained affected, the methotrexate was considered "on target" and continued. Otherwise, doctors added sulfasalizine, and were assessed again after four weeks. Every four weeks, if a treatment did not significantly improve symptoms under the objective criteria patients were advanced to a more aggressive treatment.
"I was very excited about this study," said Dr. Alexis Ogdie, assistant professor of medicine and epidemiology for University of Pennsylvania's rheumatology division. "This is one of the first trials to help us better understand how frequent follow-ups and tweaks in medications can make patients better," Ogdie said.
Under standard care in the U.K., patients see their doctors every 12 weeks, and the decision whether to continue or to escalate treatment is subjective. "Usually we just ask how patients are doing," Coates said.
By assessing the patients every four weeks, doctors were able to ramp-up treatments for patients in the "treat-to-target" group in about one-third of the time it would take under standard care, if not more quickly. By the end of the trial, biologics had been prescribed to five times as many treat-to-target patients as to patients under standard care.
A similar approach is already the standard for treating rheumatoid arthritis both in the United States and the U.K.
Really establishing that kind of approach with psoriatic arthritis, will require follow-up, Ogdie said.
"One of the most important things is to understand whether treating people aggressively like this actually decreases the risk of deformities and permanent joint damage," Ogdie said. She said 48 weeks was insufficient to establish this.
The study considered whether a more aggressive treatment regimen increased the frequency of so-called adverse events, because all of the drug treatments have the effect of suppressing a person's immunity to infection. Considered case-by-case, Coates said, only three out of 100 patients suffered serious infections that might have been the result of aggressive therapy. By comparison, two of the patients under standard care suffered serious infections.
"For patients with active disease that is significantly impacting on their quality of life … it makes us think that that was a reasonable trade-off," Coates said.
November 5, 2013